The Pelvis Hip Thigh Injuries of the Athlete

8/14/2019 The Pelvis Hip Thigh Injuries of the Athlete

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The Pelvis, Hip and Thigh

Introduction

Biomechanics

Contusion of Quadriceps

Myositis Ossificans Traumtica

Quadriceps Strain and Ruptures

Avulsions of the Iliac Spines

Hamstring Strains

Ischial Apophysitis

Groin Strains

Hip Pointer and Fracture Iliac Crest

Iliac Crest Apophysitis and Avulsion

Trochanteric Bursitis and Snapping Hip

Hip Strain and Conjoint Tendon Strain

Osteitis Pubis

Nerve Entrapment

Labral tears

Stress fractures

Fractures

Dislocations

Hip Arthroscopy

Avascular Necrosis Femoral Head

Osteoarthritis

Introduction

Injuries of the hip, thigh and pelvis are common.

The hip is poorly designed, we stand on the end of a lever ( NOF, neck of femur). So BW ismagnified about the anatomical axis of the leg; it is no wonder that the NOF breaks soeasily and often(meaning until recently, the end of life from mechanical failure of themusculoskeletal system).


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Apart from fractures, such injuries cam be subtle and difficult to diagnose. Especially beforethe advent of widespread MRI scanning.

Careful examination and investigation will help (possibly arthroscopy).

Contusions, strains, tears and avulsion fractures may form a continuum of injuries to thisregion. The more obvious fractures and dislocations may be limb or life threatening.

1

Biomechanics of the Hip

The hip is a ball and socket joint with simultaneous motion in all 3 planes (up to 120 of

flexion, 20 of abduction and 20 of external rotation). The joint reactive forces are 3 to 6times body weight due to contraction of the large muscle groups about it.

The acetabulum has a fibrocartilaginous rim (labrum) to deepen it and so add furtherstability. Its floor is almost paper thin. The postero-superior surface of the acetabulum isthickest to accommodate weight-bearing. The neck forms an angle of about 125 with theshaft and is 20 anteverted. The hip capsule drops down across the front of the neck butonly part-way at the back. It is reinforced by three ligaments (the ilio-femoral ligament of Bigelow is the strongest). The major blood supply to the head is from the medial circumflexbranch (of the profunda femoris) which is at risk from fractures of the neck of femur anddislocations.

Contusion of Quadriceps (cork thigh, Charley Horse)

Contusion is the general result of a direct blow during contact sports and varies from mild tosevere. They are often worse when the muscle is relaxed. The injury commonly occurs inthe musculotendinous junction of the rectus femoris (Fig.1).

Clinical features. There is pain, stiffness, a limp, and progressive swelling and bruising.The pain is exacerbated by resisted knee extension and hip flexion. Due to bleeding in thesoft tissues the pain and limitation of movement often becomes worse over the subsequent48 hours.


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DO NOT DO AN MRI WHICH WILL ONLY CONFUSE THE ISSUE. X RAYS AND A CLEAR HX OF INJURY ARE SUFFICIENT .

These injuries can be classified according to that of Jackson and Fagin (1973) (Fig. 2).

Figure 2

Classification of Contusions

Mild

Moderate

Severe

Characterised by localised tenderness in the quadriceps, knee motion of 90

degrees or more, non alteration of gait. The athlete is able to do a deep knee

bend.

Characterised by swollen tender muscle mass, less than 90 degrees of knee

motion and antalgic gait. The athlete is able to do knee bends, climb stairs, or

arise from a chair without pain.

Thigh is markedly tender and swollen and the contours of the muscle cannot

be defined by palpation. Knee motion is less than 45 degrees and there is a

severe limp. The athlete prefers to walk with crutches and frequently has an

effusion in the ipsilateral knee.

Treatment

Jackson and Fagin initially described three phases in the treatment. The first phase waslimitation of motion to minimize haemorrhage. This included rest, ice, compression andelevation. The leg was maintained in extension and quadriceps isometric exercises wereallowed.


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Phase 2 was the restoration of motion and this was depended upon the condition of thequadriceps stabilizing and the patient being pain free at rest. Continuous passive motiongravity assisted motion. Supine and prone inactive knee flexion was encouraged along with

isometric quadriceps exercises. Once a pain free passive range of motion of 0 to 90 degreeshas been achieved, along with good quadriceps control, the programme can be progressedto static cycling with increasing resistance. The conclusion of this phase is marked byrestoration of motion of more than 90- degrees, and normal crutch free gait.

The third phase is functional rehabilitation with progressive increasing resistance exercisesto help with strength and endurance. The essence of this program is that it shouldalways be pain free.

Myositis Ossificans Traumatica

This is a sever contusion or tear in the quadriceps mainly with haematoma formationfollowed by acute inflammation. Fibroblasta may then form osteoid (Fig. 3) Ryan (1991) in a3 year study found 17 quadriceps contusions in Westpoint Cadets and found an instance of myositis ossificans of 9%. The majority of these occurred in moderate or sever contusions.It was interesting to note that no cadet with a knee range of motion greater than 120

degrees at initial evaluation developed myositis ossificans. Specific risk factors wereidentified.

1. Knee motion of less than 120 degrees.

2. Injury associated with football

3. A previous quadriceps injury

4. Delay in treatment greater than three days

5. Ipsilateral knee effusion


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Clinical features - pain was localised to the anterior aspect of the thigh associated withfluctuant mass which evolved into a hard mass at the two to four week mark. This canresolve after six months if the injury is low grade and in the muscle belly involvement of themusculotendinous region.

Treatment as for contusion of the quadriceps. Aspiration or open drainage of thehaematoma may be necessary. The use of femoral nerve blocks non-steroidal anti-inflammatories and radiotherapy have been advocated with some success.

Quadriceps Strains and Ruptures

These injuries are the result of a severe contraction when either accelerating or kicking. Therectus femoris is the most commonly affected with the injuries usually more distal than the

thigh.

Clinical features include localised tenderness or a defect (Fig. 4). The pain is exacerbatedby resistance of hip flexion in extension and full knee flexion in a prone position. MRIs willoften confirm the site with a high signal on a T2 weighted image corresponding to the areaof inflammation and oedema.

Pain in the anterior aspect of the thigh needs to be differentiated from an L3 nerve rootlesion.

Treatment follows that already outlined for quadriceps contusion.

Avulsions of the iliac spines superior and inferior

Mechanism of injury is a sudden severe contracture of the rectus femoris muscle,(occasionally the sartorius muscle) (most common in soccer players) (Fig. 5). Players tendto be in their mid teens.

Clinical features - include significant pain, tenderness and bruising, and the x-ray isusually diagnostic (Fig. 6). Treatment includes rest, ice, compression and elevation. If there is persisting functional impairment then surgery may be necessary to fix theapophysis or avulsed fragment. On occasions, and often at a later date, the bone fragmentmay need to be excised.


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Hamstring Strains

In the late swing phase of the gait cycle, hamstrings decelerate the limb. With sudden

acceleration from the stabilizing flexion to active extension, strain is put on the hamstringmuscles. This injury is most likely to occur with sudden hamstring contraction in athleteswhen they are cold or have not done adequate stretching. Common situations are at thestarting blocks, sprinters at take off, (or high jumpers and long jumpers) and suddenacceleration or resisted extension by football players (Fig. 7).

The short head of the biceps femoris is most commonly affected. Occasionally dystrophiccalcification is seen.

The patient may describe a twinge or a snap and localise an area, quite often the region of the short head of the biceps as the most tender. Swelling and a palpable defect arecommon.

Treatment includes rest, ice, compression, elevation and physiotherapy (local cryotherapyand ultrasound). A stretching programme is commenced once pain has subsided.

The recovery time can be from days to weeks depending upon the severity of the injury.

The key to treatment is to remedy poor training techniques and improveflexibility . The athlete must carry out an adequate warm-up and stretching programmeprior to a return to sporting activities. The significant imbalance between quadriceps andhamstrings needs to be overcome, and adequate return hamstring strength before returningto sport. The use of a firm elasticised support is a desirable adjunct.

Ischial Apophysitis (Weavers Bottom, Ischial Bursitis) and Avulsions

This is the result of excessive running, especially in adolescents. Repetitive strain is putupon the apophysis and compounded by tight hamstrings. Severe contracture of thehamstrings musculature may avulse the tuberosity (see Fig. 22, Chapter 18).

There is a dull ache and tenderness in the area of the apophysis and often associatedtightness of hamstrings. Ecchymosis and a palpable defect may also be present.


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An x-ray may show fragmentation or avulsion of the apophysis.

Treatment includes rest, ice, compression, elevation and physiotherapy and a flexibility

programme as per a hamstring strain. Significant displacement or functional disability maynecessitate surgical fixation of the apophysis.

Groin Strains (Adductor Strain)

The groin is an ill-defined area but for the most part injuries in this area involve theadductor muscles. Exclude fractures, avulsions, hip joint injuries, inflammation of the pelvic

joints, bursitis about the hip, snapping hip, nerve entrapment and various forms of referredgroin pain from hernias, prostates, urinary infections, gynaecological disorders,rheumatological diseases, bone infections and tumours.

This occurs in sports where cutting, side stepping or pivoting are required, especially insoccer and rugby players. There is a violent external rotation with the leg in a widelyabducted position (Fig. 8). Generally occurs at the musculotendinous junction. Injuries areoften acute-on-chronic disruptions due to increased collagen at the musculotendinous

junction, and thereby reducing extensibility.

The injured athlete often describes a sudden knife-like pain in the groin area, and bruisingand swelling may be noted but tenderness is well localised. The pain is exacerbated byadduction against resistance (Fig. 9). In chronic cases the symptoms may be somewhatvaguer and diffusely located. Renstrom (1980) described pain with exercise as mostcommon but also at rest often associated with stiffness in the morning, and some weakness.

MRI confirms the adductor longus as the solely affected muscle.

Treatment includes rest, ice, compression and elevation. After the initial 24 to 48 hours

haemorrhage should have ceased and physiotherapy modalities (cryotherapy andultrasound). Anti-inflammatory medication may be useful for short periods in chronic cases.A stretching programme should be commenced and isometric contractions of the muscleswithout resistance followed by the gradual introduction of resistance within the limits of pain.


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Some attention should be paid to a lack of flexibility and improved training techniques. Useof an elasticised tape for support may be beneficial. Steroids occasionally are of benefit in achronic situation.

Surgery should not be contemplated without a prolonged period of conservativemanagement of a minimum to six to twelve months. A release of the adductor longustendon is carried out with the hip in a flexed and abducted position. If a degenerate noduleis identified this should be debrided, failing this a tenotomy is often sufficient.

A Grade III complete rupture is very uncommon (it occurs at the femoral attachment). Inselected cases surgical repair is desirable.

Hip Pointer and Fracture of the Iliac Crest

This is the result of a direct blow to the iliac crest resulting in bruising, a fracture or musclefibre separation (Fig. 10).

Seen in contact sports either from a tackle or due to a fall on to the area of the iliac crest.

Clinical features include maximum tenderness that is frequently over the mid point of theiliac crest corresponding to the divergence of abdominal and lumbar musculature wherethere is muscle fibre separation. Otherwise the area of tenderness may be anywhere alongthe iliac crest. Swelling and Ecchymosis are progressive over the subsequent 24 hours. X-rays are important to rule out a fracture and later x-rays may show periostitis or exostosisformation.

Treatment includes rest, ice packs, compression and elevation in the first 24 hours.Occasionally aspiration and injection of local anaesthetic can give good symptomatic relief.

After the phase of bleeding has ceased, ultrasound and other physical therapy modalitiesmay be introduced. Protective padding should be used if returning to contact sports.

Iliac Crest Apophysitis and Avulsion


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Mechanism This may result from repetitive stress in adolescents especially running witha cross-over style of arm swing. Severe contraction or a direct blow may avulse the iliaccrest.

Clinical features tenderness may be anteriorly or posteriorly in the iliac crest dependingupon whether tensor fascia lata, gluteus medius or oblique abdominal muscles areresponsible for the increased strain. Resistance to abduction and contralateral flexion of thetrunk frequently exacerbates the pain.

X-rays are essential to exclude avulsion of the iliac apophysis.

Treatment includes rest, ice, compression and elevation and physical therapy. It may benecessary to change the athletes running action and gradually reintroduce activities.

Occasionally surgery is necessary to relocate the avulsed iliac crest.

Trochanteric Bursitis and Snapping Hip

Trochanteric bursitis is inflammation of the bursa over the greater trochanter region as aresult of increased shear stress created by the iliotibial band over the trochanter (Fig. 11).This is often associated with a broad pelvis and large quadriceps angle (Q-angle). Leg lengthdiscrepancies, pelvic tilt or cross over type running style may also be implicated. Asnapping hip is due to thickening of the posterior part of iliotibial band which produces apainless snapping sensation.

Clinical features include pain over the lateral aspect of the thigh when lying on the affectedside (in the posterior and lateral aspect of the trochanter). Abducting against resistance inan internally rotated position can exacerbate the pain. A snapping sensation may be notedwith the patient standing with the knee extended and pushing the hip into an abducted andflexed position.

Another form of snapping hip is derived from repetitive rubbing of the capsule in running orballet which involves the iliopsoas tendon (Fig. 12).

Clinical features include pain around the medial aspect of the groin which occurs withrotation of the hip. Resistance to flexion of the hip from 90 degrees of flexion leads to


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increased pain and tenderness in the groin. Clicking may be reproducible in some instances.It is important to note that pain can sometimes be referred from the lumbosacral spine orsacroiliac joint to this area and must be differentiated from these conditions.

Treatment includes rest, ice, compression and elevation followed by ultrasound andstretching of the iliotibial band and iliopsoas to overcome contractures. It is important tocorrect any leg length discrepancy or abnormal running style and orthotics will occasionallybe warranted. Steroid injections and anti-inflammatories may be useful in acute bursitis.Surgery has a limited place and should not be contemplated without a prolonged period of conservative management. Surgical technique involves Z-plasty of the iliotibial band.

Hip Strain (Pericapsulitis, Synovitis, Irritable Hip)

The result of a direct blow, twisting injury, or from overuse of the hip. Inflammation of thelining or a strain or capsular ligaments occurs (Fig. 14).

This results in pain in the groin, radiating into the thigh. The position of comfort is flexion,abduction and external rotation. Pain is exacerbated by extension and internal rotation (Fig.15). Antalgic gait may be noted.

Exclude infection (especially in children). X-rays may show some joint widening and a bonescan is often positive.

Treatment includes R.I.C.E. and non-weight bearing. Often complete bed rest (with springsand slings) in children, until complete resolution of symptoms. If capsular tightening occursthen a flexibility programme is required.

Conjoint Tendon Strain of the Hip

This injury results from stress on the abdominal musculature, as in a mark in football or

heading in soccer.

The athlete experiences pain and tenderness over the superior pubic ramus (Fig. 16). Hipmovements are full. X-rays are normal. The bone scan is occasionally diagnostic.


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Treatment is R.I.C.E., physical therapy and a flexibility programme. Only occasionally issurgical repair necessary.

Osteitis Pubis

This is a non-suppurative self limiting necrosis in the bone of the pubis and synchondrosis.

It occurs from repetitive shear stress across the symphysis in running and kicking sportswhich leads to a subacute periostitis.

Clinical features include a gradual onset of groin discomfort which deteriorates with further

activity. Severe pain may be experienced when jumping. Tenderness is maximum over thesymphysis and the body and rami of the pubis. Pain is aggravated by pelvic compression,full flexion, wide abduction of the hips and even sit-ups. Exclude hernias, groin strains andprostatitis in males. X-ray changes are delayed for at least a month but manifest withperiosteal reaction and demineralization of the subchondral bone leading to a moth eaten appearance around the symphysis. In the most severe cases erosion can lead to instabilitywhich can be detected in single leg weight bearing views of the pelvis.

Bone scans are often positive in the early stages (Gallium scans may be useful to exclude aninfection).

Treatment includes rest, NSAIDS and occasionally steroid injections in chronic cases. Aftercessation of symptoms, gradual reintroduction of a flexibility programme and a progressiveincrease in weight bearing should be instituted. It may take up to 12 months for completerecovery.

Nerve Entrapment

The commonest nerves involved are the ilioinguinal nerve, obturator nerve, genitor-femoralnerve and lateral cutaneous nerve of the thigh (Figs 17 and 18). Although the mechanism isunknown in most cases, hypertrophy of muscles (hypertrophied abdominal muscles mayconstruct the ilioinguinal nerve; enlarged hip adductors in skaters may constrict theobturator nerve) or scarring as a result of previous injuries are the most likely causes. Athorough knowledge of the distribution of the nerves will help in making a diagnosis and


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these areas are likely to exhibit pain and paraesthesia. Tenderness may be experienced overthe subcutaneous emergency of the nerve. EMG may occasionally be helpful in confirmingnerve entrapment.

Rest and the occasional introduction of local steroid injections are the first line of treatment,but if symptoms persist then surgical release may be necessary.

Labral Tears

These are seen in dysplastic hips where there is abnormal shear and strain on theacetabular labrum. It may also occur with excessive twisting in sports.

There is sharp pain or a catching sensation on a background of a dull ache. It is aggravatedby flexion and internal rotation of the hip. X-rays may show evidence of acetabulardysplasia. Tears are confirmed by arthrography or arthroscopy (usually in the posterioraspect of the hip joint) (Fig. 19).

Treatment is rest and surgical excision or repair.

Stress Fractures

This entity was first described by Briethaupt in 1855 in German soldiers. Stechow first notedthese on x-rays in 1897. Stress fractures of the neck of femur were first described byBlecher in 1905. Much of the early literature relating stress fractures was from the military.There is an increasing prevalence of stress fractures in athletes and this, interestingly, ismore often found in highly motivated athletes who are in peak condition and following aperiod of maximal performance. Commonly identified risk factors in athletes are endocrinedisorders particularly in amenorrhoeic female athletes (see Chapter 18).

They are a process of partial or complete fracture of bone due to an inability to withstandnon-violent stress that is applied in a rhythmic repeated submaximal mode.

There is controversy as to whether or not the condition is due to fatigue of muscles leadingto increased load or as Stanitski believes, an increased muscular force plus increased rate of


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remodelling leading to resorption and rarefaction and ultimately to stress fractures. This willmanifest itself as a periosteal or endosteal response giving an appearance of a stressfracture which may ultimately progress to a linear fracture and in time displace.

The clinical and x-ray criteria for diagnosis of a stress fracture are outlined (Fig. 20).

Figure 20

Clinical and x-ray criteria for diagnosis of stress

fractures

Premorbid normal bone

No direct trauma/inciting activity

Pain and tenderness (on percussion and

antalgic limp) prior to x-ray changes

Subsequent x-rays show resolution and

modeling

Positive bone scan

Assess the opposite side both clinically an by x-ray to exclude a stress fracture (as notalways symptomatic). Differential diagnosis includes tumour (particularly osteosarcoma and

Ewings tumour), Osteomyelitis or periostitis from TB or syphilis. Jumping sports have astrong association with injuries to the femur and pelvis but stress fractures have beennoticed amongst hikers and fencers especially in the pelvic bones.


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These injuries can be classified into those affecting the femoral neck and the femoral shaft(Fig. 21).

Figure 21

Stress Fractures Femur

Femoral Neck (Devas and Hiajeck)

Compressive of inferior cortex young

patients/early/internal callus/fracture/sclerosis (Fig. 22)

Non-weight bear/modify training

transverse of superior cortex -= older patients/initial

crack in superior cortex/fracture/displaced fracture

Operate

Femoral shaft (Morris and

Blickenstaff)

Medial proximal femur

Displaced spiral oblique

Transverse distal

Operate

Treatment involves decreased weight bearing and modifying training. This may be sufficient

in early femoral shaft stress fractures and compressive variety of femoral neck fractures. Inthe older patient it is wise to pin these at an early stage as there is a risk of progression. Adegree of suspicion by medical and training staff is necessary to ensure that both eliteathletes and amateurs do not suffer significant stress fractures. From finite element analysisit is recommended that a maximum 100 miles over a three month period be the limit for afirst time jogger.


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Fractured Hip; Acute Slip of the Upper Femoral Epiphysis (SUFE)

These injuries occur from a severe impact while the foot is planted and the hip twisted.They may occur in cross country and downhill skiers from a low velocity fall (Skiers HIP)

(Fig. 23). (Hip fracture may occur or SUFE in child) (see Figs. 23-25, Chapter 18).

There is severe pain and an inability to weight bear, with shortening and external rotation inthe hip. Exclude a past history of ache or an antalgic gait with an acute or chronic slippedupper femoral epiphysis (Fig).

Treatment is immediate immobilisation and then immediate operative stabilisation anddrainage of the capsular haematoma.

Dislocation of the Hip (EMERGENCY)

Dislocations are the result of a direct impact to the flexed knee and hip (anterior orposterior).

The athlete has severe pain and deformity with the leg in a flexed and internally rotatedposition (posterior dislocation) or externally rotated (anterior dislocation) (Fig. 24 and 25).There may be associated sciatic nerve injury.

Immobilise the athlete and plan immediate reduction (open if necessary) of the hip toreduce the likely development of AVN.

Fractured Femur and Pelvis

These are high velocity injuries (Figs. 26 and 27).

Significant pain and deformity occurs. Exclude neurological or vascular compromise. Thereare associated head, neck, chest and abdominal life threatening injuries which must befound and treated.

Resuscitate the athlete with special attention to head injury, immobilise the neck, excludeneed for chest tude/peritoneal lavage/exploratory laparotomy. Optimise volumereplacement (up to 40 units of blood can disappear into a fractured pelvis) and give


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adequate analgesia. Surgery is almost always required to reduce and hold fractures of thefemur and quite often for the pelvis (external fixation to tamponade bleeding in displacedand unstable pelvic fracture (Figs. 28 and 29).

Hip arthroscopy Bowman first reported hip arthroscopy being performed in 1937. It hasonly recently become more widely used but even to this day, the uses, apart fromdiagnostic, are fairly limited (Fig. 30).

It is frequently used where there is unexplained hip pain, in situations of synovitis orosteoarthrosis. It may be used for lavage in early osteoarthrosis and for treatment of labraltears, removal of loose bodies (from fractures, osteochondromatosis and villonodularsynovitis). Several techniques have been described (Fig. 31).

Avascular Necrosis of the Femoral Head

This is a partial or complete disruption of the blood supply to the femoral head resulting innecrosis of a segment which may undergo collapse before revascularization has occurred(Figs. 32 and 33).

This condition most commonly follows a fracture of the head or femoral neck or dislocationespecially if associated with some delay in reduction. Posterior dislocations in particulardisrupt the superior retinacular vessels. Perthes Disease, results from an increasedintracapsular pressure following a synovitis which compromises the vascular supply to thefemoral head. This condition is classified according to that of Ficat (Fig. 34) with diagnosticand surgical intervention noted.)

Ficats Classification of AVN

Figure 21

Stage

0

None

Normal Normal Normal Normal Normal


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1

2

3

4

Minimal

Moderate

Advanced

Severe

I. Rot.

ROM

ROM

Pain

Normal

Porosis/

Sclerosis

Flat, crescent

sign

Acetabular

changes

No help

Positive

Positive

Positive

Some

Changes

Positive

Positive

Positive

?core

decompression

Graft

Joint

replacement

Joint

replacement

Osteoarthritis

This condition has a high correlation with high impact sports especially track and field andracquet sports (Figs. 35 and 36). Work performed by Radi shows that compression of the

joint with oscillating repetitive high impact loads leads to microfractures. Obviouslyconditions associated with avascular necrosis can advance the onset of osteoarthrosis.Athletes with intensive sports participation have a 4 to 5 fold increased incidence of OA(upto 8.5 if also involved in an occupation at risk of OA). Patients who have had hipreplacements should not play impact sports.

Whether Surface Hip Replacements represent a real choice for young people with OA of thehip, remains to be seen. But certainly MIS techniques should be used when THR isundertaken to accelerate rehanb..

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The Pelvis Hip Thigh Injuries of the Athlete